1Madison County Rescue Squad

Madison County Rescue Squad, Inc

Volunteer Membership Application
We are an equal opportunity organization and do not unlawfully discriminate in membership. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for membership on a basis prohibited by local, state or federal law. Equal access to membership, services and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the organization.
- Full Name
  
  First NameMiddle NameLast NameSuffix
- Maiden Name (if applicable)
  
  First NameMiddle NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- E-mail
- Phone Number
  
  Area CodePhone Number
- Work Phone:
- Cell Phone:
- Birth Date
  
  MonthDayYear
- Age
- Race
- Employer or School
- Do you have a valid Motor Vehicle License?
- If yes, License number
  MCRS is required to run a DMV Record Information Request
- Do you have a High School Diploma or G.E.D?
- SSN
  Required...MCRS is required to run a Criminal History Record
- Current Certifications
  
  You will be required to submit copies of certification cards when requested. You will be contacted and given further direction prior to being voted into membership with Madison County Rescue Squad
- Healthcare CPR
- Health care - Year Complete
- Health care - Year Expires
- EVOC
- EVOC Class
- EVOC Expiration
- EMT-B
- EMT-B Expiration Date
- EMT-B License Number
- EMT-E
- EMT-E Expiration Date
- EMT-E License Number
- EMT-I
- EMT-I Expiration Date
- EMT-I License Number
- EMT-P
- EMT-P Expiration Date
- EMT-P License Number
- Health Statement: Do you have any physical impairments?
- If Yes to Health Statement, please explain
- Please furnish three (3) references - No relatives please with one (1) reference being a previous Supervisor.
- Full Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Phone Number
  
  Area CodePhone Number
- E-mail
  Email, if known
- Full Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Phone Number
  
  Area CodePhone Number
- E-mail
- Full Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Phone Number
  
  Area CodePhone Number
- E-mail
  Email, if known
- Agency
- Years with Agency
  Provide start month and year along with end month and year when you left agency
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Phone Number
  
  Area CodePhone Number
- Contact Person
- Agency
- Years with Agency
  Provide start month and year along with end month and year when you left agency
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Phone Number
  
  Area CodePhone Number
- Contact Person
- Do you have any objection to working weekends and holidays?
- Have you ever been previously a member of our organization?
- If you are under 18 or in school can you furnish a copy of your last report card? MCRS wants to make sure if you are in high school, you keep your grades up. We do not want them to suffer!
- MCRS and/or MEMS is required to run a criminal history record name search before you application will be accepted. Failure to submit the form will delay your application acceptance. The membership LT. of MCRS will give yoy this information once they meet with you in person.
- Are you a minimum of 16 years of age? (12 VAC 5-31-900. General requirements.)
- Are you willing and able to maintain a clean and neat appearance in accordance with Virginia rules/regulations, etc.? (12 VAC 5-31-900. General requirements.) And in accordance with the Madison County Rescue Squad, Inc Constitution and Bylaws and abide by all rules, regulations and Standard Operating Procedures established by the Madison County Rescue Squad, Inc
- Are you proficient in reading, writing and speaking the English language in order to clearly communicate with a patient, family or bystander to determine a chief complaint, nature of illness, mechanism of injury and/or assess signs and symptoms? (12 VAC 5-31-900. General requirements.)
- Do you have a physical or mental impairment that would render you unable to perform all practical skills required for that level of training? Physical and mental performance skills include the ability of the individual to function and communicate independently to perform appropriate patient care, physical assessments and treatments without the need for an assistant. (12 VAC 5-31-900. General requirements.)
- Have you ever been convicted or found guilty of any crime involving sexual misconduct where the lack of affirmative consent by the victim is an element of the crime, such as forcible rape? (12 VAC 5-31-910. Criminal or enforcement history.)
- Have you ever been convicted of a felony involving the sexual or physical abuse of children, the elderly or the infirm, such as sexual misconduct with a child, making or distributing child pornography or using a child in a sexual display, incest involving a child, assault on an elderly or infirm person? (12 VAC 5-31-910. Criminal or enforcement history.)
- Have you ever been convicted or found guilty of any crime in which the victim is an out-of-hospital patient or a patient or resident of a healthcare facility including abuse of, neglect of, theft from, or financial exploitation of a person entrusted to the care or protection of the applicant?(12 VAC 5-31-910. Criminal or enforcement history.)
- Serious crimes of violence against persons such as assault or battery with a dangerous weapon, aggravated assault and battery, murder or attempted murder, manslaughter except involuntary manslaughter, kidnapping, robbery of any degree, or arson. (12 VAC 5-31-910. Criminal or enforcement history.)
- Has been subject to a permanent revocation of license or certification by another state EMS office or other recognized state or national healthcare provider licensing or certifying body? (12 VAC 5-31-910. Criminal or enforcement history.)
- Have you been convicted of any crime and are you currently incarcerated, on work release, on probation, or on parole? (12 VAC 5-31-910. Criminal or enforcement history.)
- Have you been convicted of crimes in the following categories unless at least five years have passed since the conviction or five years have passed since release from custodial confinement whichever occurs later: 1. Crimes involving controlled substances or synthetics, including unlawful possession or distribution or intent to distribute unlawfully Schedule I through V drugs as defined by the Virginia Drug Control Act (§ 54.1-3400 seq. of the Code of Virginia). 2. Serious crimes against property, such as grand larceny, burglary, embezzlement, or insurance fraud. 3. Any other crime involving sexual misconduct. (12 VAC 5-31-910. Criminal or enforcement history.)
- Are you currently under any disciplinary or enforcement action from another state EMS office or other recognized state or national healthcare provider licensing or certifying body. Personnel subject to these disciplinary or enforcement actions may be eligible for certification provided there have been no further disciplinary or enforcement actions for five years prior to application for certification in Virginia? (12 VAC 5-31-910. Criminal or enforcement history
- Have you ever been subject to a permanent revocation of license or certification by another state EMS office or other recognized state or national healthcare provider licensing or certifying body? (12 VAC 5-31-910. Criminal or enforcement history.)
- Have you been convicted upon a charge of driving under the influence of alcohol or drugs, convicted of a felony or assigned to any alcohol safety action program or driver alcohol rehabilitation program pursuant to § 18.2-271.1 hit and run, or operating on a suspended or revoked license within the past five years. EMS personnel may not act as an operator of an EMS vehicle if they have been convicted. A person having any of these convictions in Virginia or another state may be eligible for reinstatement as an operator after five years and after successful completion of an approved emergency vehicle operator's course (EVOC) within the year prior to reinstatement. (12 VAC 5-31-910. Criminal or enforcement history.)
- Will you comply with all federal, state, and local laws applicable to their EMS operations? (12 VAC 5-31-930. State and federal law compliance.)
- All references to criminal acts or convictions under this section refer to substantially similar laws or regulations of any other state or the United States. Convictions include prior adult convictions, juvenile convictions and adjudications of delinquency based on an offense that would have been, at the time of conviction, a felony conviction if committed by an adult within or outside Virginia. (12 VAC 5-31-910. Criminal or enforcement history.)Have you ever been convicted of a crime in the last 7 years?
- If yes, please explain
- I hereby authorize theChief, Madison County Rescue Squad, Inc., or his/her designee to contact, obtain, and verify the accuracy of information contained in this application from all previous agencies, organizations, employers, educational institutions, and references. I also hereby release from liability the Madison County Rescue Squad, Inc. and its representatives for seeking, gathering, and using such information to make membership decisions and all other persons or organizations for providing such information.
  
  I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of membership if I am a member, whenever it may be discovered.
  
  If I become a member, I acknowledge that there is no specified length of membership and that this application does not constitute an agreement or contract for membership. Accordingly, either I or the Madison County Rescue Squad, Inc. can terminate the relationship at will, with or without cause, at anytime, in writing so long as there is no violation of applicable federal or state law.
  
  As a member of the Madison County Rescue Squad, Inc., I shall not consume alcoholic beverages or harmful drugs (illegal) while on duty, at Squad functions, or at the Squad Building. In addition I shall attend all meetings and drills (unless excused), cleanups and Squad functions. Also I shall conduct myself in a professional manner whenever representing the Madison County Rescue Squad, Inc or the Madison County EMS. in any way
  
  I understand that it is the policy of this organization not to refuse membership or otherwise discriminate against a qualified individual with a disability because of that person’s need for a reasonable accommodation as required by the ADA. I represent and warrant that I have read and fully understand the foregoing, and that I seek membership under these conditions.
- Signed
  Electronic signature constitutes submittal of application
- Date submitted
  
  MonthDayYearHourMinutesAM/PM Option
- Signed
  Parent/Guardian must sign and date if applicant is between 16-18 years old
- Date Submitted
  
  MonthDayYearHourMinutesAM/PM Option
- Enter the message as it's shown
- E-mail
- E-mail
- Should be Empty:

Madison County Rescue Squad, Inc